Psychological and Psychiatric Support; When, Why and What to Do

Postural tachycardia syndrome (PoTS) is neither a mental health disorder nor is it caused by mental health issues. Nonetheless, like all health conditions, mental health difficulties can negatively impact on outcomes in PoTS. Anxiety and mood disturbances can be precipitated by the symptom burden, and may exacerbate symptoms thereafter if not well managed. Clearly, there are significant quality of life (QoL) impacts for people with PoTS to adjust to. There is some controversy about whether mood and anxiety disorders are more common in those with PoTS. Review of the literature suggests that mood challenges in PoTS are equivalent to other health disorders with equivalent magnitude of symptom burden and disability. The anxiety seen in PoTS patients seems to take a specific form and be somatically and attentionally based, rather than cognitive. Indeed, PoTS is associated with evidence of sympathetic dysregulation with symptoms overlapping with somatic aspects of anxiety. This can easily be mistaken for anxiety by observers, or misinterpreted as threatening or scary by the patient; thereafter initiating or exacerbating an anxious response cycle. Effective management therefore requires a balance of symptom monitoring and acceptance/tolerance of the symptoms. Over-attending can easily tip over into hyper-vigilance, which can cause an anxiety disorder. Conversely, and quite commonly in clinical practice, patients can present with dissociative coping strategies to avoid unpleasant sensations and emotions. There is also some evidence that PoTS compromises cognitive functioning, which can be distressing for patients and potentially affect their ability to engage in daily educational and occupational activities. PoTS patients often have a history of pushing through pain or discomfort to get on and achieve what they need to. This can result in a ‘boom and bust’ profile, and possibly syncope (where physical pre-syncopal cues are tuned out as well as other PoTS symptoms). Conversely, some patients with PoTS are so adept at compensating for autonomic dysregulation that they are less likely to faint than the general population. Since PoTS has a unique thumbprint in each patient, generalizations must be made with caution. Review of the psychological data suggests, however, that most patients would benefit from high quality and timely support to help them manage this challenging condition, and in this chapter we suggest therapeutic considerations and approaches for interested clinicians.